Pages 1-2,
Part 1. Information
About You
|
[Page 1]
Start Here. Type or print in
black ink.
Part 1. Information About You
…
Your Full Name
2.a. Family Name (Last Name)
2.b. Given Name (First Name)
2.c. Middle Name
Other Names Used
List all other names you have ever
used, including maiden names, aliases, and nicknames. If you need
extra space to complete this section, use the space
provided in Part 8. Additional Information.
3.a. Family Name (Last Name)
3.b. Given Name (First Name)
3.c. Middle Name
Mailing Address
NOTE: If you are outside the
United States, provide a U.S. mailing address, if available. If
a U.S. mailing address is not available, provide your mailing
address abroad.
4.a. In Care Of Name
4.b. Street Number and Name
4.c. Apt. Ste. Flr.
4.d. City or Town
4.e. State
4.f. ZIP Code
4.g. Province
4.h. Postal Code
4.i. Country
5. Is your mailing
address the same address where you currently live (physical
address)? Y/N
If you answered "No" to
Item Number 5., provide your current physical
address in Item Numbers 6.a. - 6.h.
[page 2]
Physical Address
6.a. Street Number and Name
6.b. Apt. Ste. Flr.
6.c. City or Town
6.d. State
6.e. ZIP Code
6.f. Province
6.g. Postal Code
6.h. Country
Other Information About You
7. U.S. Social Security
Number (if any)
[new]
8. Gender M/F
9. Date of Birth
(mm/dd/yyyy)
10. City or Town of Birth
11. State or Province of
Birth (if applicable)
12. Country of Birth
13. Country of Citizenship or
Nationality
If you seek an immigrant or
nonimmigrant visa and you are or will file your application for
consent to reapply with your immigrant or nonimmigrant visa
application, provide the information requested in Item Numbers
14.a. - 14.b.
14.a. The Department of
State (DOS) Consular Case Number (if available)
14.b. The location of the
U.S. Embassy or U.S. Consulate where your application for an
immigrant visa is being or will be made
City
Country
If you are seeking consent to
reapply in connection with your application to adjust your status
to that of a lawful permanent resident, provide information in
Item Numbers 15.a. - 15.c.
15.a. USCIS Receipt Number
(if any)
15.b. Where did you file
your application (for example, “USCIS Office Name” or
“Lockbox”)?
15.c. Date Filed
(mm/dd/yyyy)
16. Are you submitting Form
I-601, Application for Waiver of Grounds of Inadmissibility, along
with this application? Y/N
If you answered “No,”
provide the information requested below about previously
filed Forms I-601 (if any):
17.a. USCIS Receipt Number
for Form I-601 (if any)
17.b. Where did you file
your application (for example, “USCIS Office Name” or
“Lockbox”)?
17.c. Date Filed
(mm/dd/yyyy)
|
[Page 1]
START HERE
- Type or print in black ink.
Part 1. Information About You
…
[no change]
Other Names Used
Provide all
other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 9.
Additional Information.
3.a. Family Name (Last Name)
3.b. Given Name (First Name)
3.c. Middle Name
_____________________________________
4.a.
Family Name (Last Name)
4.b.
Given Name (First Name)
4.c.
Middle Name
Mailing Address
[no change]
5.a.
In Care Of Name (if any)
5.b.
Street Number and Name
5.c.
Apt. Ste. Flr.
5.d.
City or Town
5.e.
State
5.f.
ZIP Code
5.g.
Province
5.h.
Postal Code
5.i.
Country
[Page 2]
6.
Is your mailing address the same address where you
currently live (physical address)? Yes/No
If you answered "No" to
Item Number 6.,
provide your current physical address in Item Numbers 7.a.
- 7.f.
Physical Address
7.a.
Street Number and Name
7.b.
Apt. Ste. Flr.
7.c.
City or Town
7.d.
State
7.e.
ZIP Code
7.f.
Province
7.g.
Postal Code
7.h.
Country
Other Information About You
8. U.S.
Social Security Number (if any)
9. USCIS
Online Account Number (if any)
10.
Gender M/F
11.
Date of Birth (mm/dd/yyyy)
12.
City or Town of Birth
13.
State or Province of Birth (if applicable)
14.
Country of Birth
15.
Country of Citizenship or Nationality
If you seek an immigrant or
nonimmigrant visa and you are or will file your application for
consent to reapply with your immigrant or nonimmigrant visa
application, provide the information requested in Item Numbers
16. - 17.b.
16.
The Department of State (DOS) Consular Case Number (if available)
The Location
of the U.S. Embassy or U.S. Consulate Where
Your Application for an Immigrant
Visa is Being or Will
Be Made
17.a.
City or Town
17.b.
Country
If you are seeking consent to
reapply in connection with your application to adjust your status
to that of a lawful permanent resident, provide information in
Item Numbers 18.a. - 18.c.
18.a.
USCIS Receipt Number (if any)
[Page 3]
18.b.
Where did you file your application (for example, "USCIS
Office Name" or "Lockbox")?
18.c.
Date Filed (mm/dd/yyyy)
19.
Are you submitting Form I-601, Application for Waiver of
Grounds of Inadmissibility, along with this application? Y/N
If you answered "No,"
provide the information requested in Item
Numbers 20.a. - 20.c. about
previously filed Forms I-601 (if any):
20.a.
USCIS Receipt Number for Form I-601 (if any)
20.b.
Where did you file your application (for example, "USCIS
Office Name" or "Lockbox")?
20.c.
Date Filed (mm/dd/yyyy)
|
Pages 2-3,
Part 2. Reasons You
Are Filing Form I-212
|
[Page 2]
Part 2. Reasons You Are Filing
Form I-212
If you are inadmissible to the
United States for the following reason, select “Yes”
and then select the appropriate boxes. If you need extra space to
complete this section, use the space provided in Part 8.
Additional Information.
Removal as a Arriving Alien
(INA section 212(a)(9)(A)(i))
…
1.d. I have been convicted
of an aggravated felony in the United States or abroad, before or
after my removal from the United States. Provide information on
your aggravated felony convictions in Part 8. Additional
Information and include the required evidence.
[page 3]
2.a. Date you were removed
from the United States (mm/dd/yyyy)
2.b. Location from where you
were removed
City or Town
State
Removal as a Deportable Alien
(INA section 212(a)(9)(A)(ii))
3.a. I have been removed as
a deportable alien under INA section 240 or any other provision of
the law, or I departed the United States while an order of removal
was outstanding. Y/N
3.b. I have only been
removed once and my removal was less than 10 years ago.
3.c. I have been removed two
or more times, and my last removal was less than 20 years ago.
3.d. I have been convicted
of an aggravated felony in the United States or abroad, before or
after my removal from the United States. Provide information on
your aggravated felony convictions in Part 8. Additional
Information and include the required evidence.
4.a. Date you were excluded,
deported, or removed from the United States (mm/dd/yyyy)
4.b. Location from where you
were removed
City or Town
State
Entry After Unlawful Presence
in the Aggregate of 1 Year (INA section 212(a)(9)(C)(i)(I))
5.a. I entered or
attempted to enter the United States without being admitted or
paroled, after having been unlawfully present in the United States
on or after April 1, 1997, for a period of more than one year, in
the aggregate. Y/N
NOTE: If you answered “Yes”
to Item Number 5.a., list all the time periods during which
you were unlawfully present in the United States (including any
periods in which you overstayed your lawful status). Begin with
your most recent period of unlawful presence. Also attach
evidence demonstrating that you have remained outside the
United States for 10 years since your last departure.
Periods of Unlawful Presence
5.b. From (mm/dd/yyyy)
5.c. To (mm/dd/yyyy)
6.a. Date you departed the
United States after your period of unlawful presence (mm/dd/yyyy)
6.b. Location where you
departed the United States after your period of unlawful presence
City or Town
State
6.c. Location where you
reentered or attempted to reenter the United States
City or Town
State
6.d. Date you attempted to
unlawfully enter or reenter the United States after period of
unlawful presence (mm/dd/yyyy)
Entry After Removal (INA
section 212(a)(9)(C)(i)(II))
7.a. I entered or
attempted to enter the United States without being admitted or
paroled after having been excluded, deported, or removed. Y/N
NOTE: If you answered “Yes”
to Item Number 7.a., list all the dates when you were
excluded, deported, or removed from the United States. If you
need extra space to complete this section, use the space provided
in Part 8. Additional Information.
7.b. Date you were excluded,
deported, or removed from the United States (mm/dd/yyyy)
8.a. Location where you
reentered or attempted to reenter the United States after your
exclusion, deportation, or removal
City or Town
State
8.b. Date you entered or
attempted to reenter the United States after exclusion,
deportation, or removal (mm/dd/yyyy)
|
[Page 3]
Part 2. Reasons You Are Filing
Form I-212
If you are inadmissible to the
United States for the following reason, select “Yes”
and then select the appropriate boxes. If you need extra space to
complete this section, use the space provided in Part 9.
Additional Information.
[Page 4]
Removal as a Arriving Alien
(INA Section 212(a)(9)(A)(i))
…
1.d. I have been convicted
of an aggravated felony in the United States or abroad, before or
after my removal from the United States. Provide information on
your aggravated felony convictions in Part 9.
Additional Information and include the required evidence.
2.
Date you were removed from the United States (mm/dd/yyyy)
Location From
Where You Were Removed
3.
City or Town
4.
State
Removal as a Deportable Alien
(INA Section 212(a)(9)(A)(ii))
5.a.
I have been removed as a deportable alien under INA section
240 or any other provision of the law, or I departed the United
States while an order of removal was outstanding. Y/N
5.b.
I have only been removed once and my removal was less than 10
years ago.
5.c.
I have been removed two or more times, and my last removal was
less than 20 years ago.
5.d.
I have been convicted of an aggravated felony in the United
States or abroad, before or after my removal from the United
States. Provide information on your aggravated felony convictions
in Part 9. Additional
Information and include the required evidence.
6. Date
you were excluded, deported, or
removed from the United States
(mm/dd/yyyy)
Location From
Where You Were Removed
7.a.
City or Town
7.b.
State
Entry After Unlawful Presence
in the Aggregate of 1 Year (INA Section
212(a)(9)(C)(i)(I))
8. I
entered or attempted to enter the United States without being
admitted or paroled, after having been unlawfully present in the
United States on or after April 1, 1997, for a period of more than
one year, in the aggregate. Y/N
NOTE: If you answered "Yes"
to Item Number 8.,
list all the time periods during which you were unlawfully
present in the United States (including any periods in which you
overstayed your lawful status). Begin with your most recent
period of unlawful presence. Also attach evidence demonstrating
that you have remained outside the United States for 10
years since your last departure.
Periods of Unlawful Presence
9.a.
From (mm/dd/yyyy)
9.b.
To (mm/dd/yyyy)
10.
Date You Departed the United States After
Your Period of Unlawful Presence
(mm/dd/yyyy)
Location
Where You Departed the United States After
Your Period of Unlawful Presence
11.a.
City or Town
11.b.
State
Location Where You
Reentered or Attempted to
Reenter the United States
12.a.
City or Town
12.b.
State
13.
Date You Attempted to Unlawfully
Enter or Reenter the United
States After Period of Unlawful
Presence (mm/dd/yyyy)
[Page 5]
Entry After Removal (INA
Section 212(a)(9)(C)(i)(II))
14. I
entered or attempted to enter the United States without being
admitted or paroled after having been excluded, deported, or
removed. Y/N
NOTE: If you answered “Yes”
to Item Number 14.,
list all the dates when you were excluded, deported, or removed
from the United States. If you need extra space to complete this
section, use the space provided in Part 9.
Additional Information.
15. Date
You Were Excluded, Deported,
or Removed From the United States
(mm/dd/yyyy)
Location Where
You Reentered or Attempted to
Reenter the United States After
Your Exclusion, Deportation, or Removal
16.a.
City or Town
16.a.
State
17. Date
You Entered or Attempted
to Reenter the United States
After Exclusion, Deportation,
or Removal (mm/dd/yyyy)
|
New
|
[new]
|
[Page 6]
Part 5.
Additional Information if Filing with CBP
If you are
filing this application with Customs and Border Protection (CBP),
provide the information requested in Item
Numbers 1.a. -40.c.
Address
History
Provide
physical addresses for everywhere you have lived during the last
ten years, whether inside or outside the United States. Provide
your current address first. If you need extra space to complete
this section, use the space provided in Part
9. Additional Information.
Physical
Address 1 (current address)
1.a.
Street Number and Name
1.b.
Apt. Ste. Flr.
1.c.
City or Town
1.d.
State
1.e.
ZIP Code
1.f.
Province
1.g.
Postal Code
1.h.
Country
Dates of
Residence
2.a. From
(mm/dd/yyyy)
2.b. To
(mm/dd/yyyy) [Present]
____________________________________
Physical
Address 2
3.a.
Street Number and Name
3.b.
Apt. Ste. Flr.
3.c.
City or Town
3.d.
State
3.e.
ZIP Code
3.f.
Province
3.g.
Postal Code
3.h.
Country
Dates of
Residence
4.a. From
(mm/dd/yyyy)
4.b. To
(mm/dd/yyyy)
Employment
History
Provide your
employment history for the last ten years, whether inside or
outside the United States. Provide the most recent employment
first. If you need extra space to complete this section, use the
space provided in Part 9.
Additional Information.
Employer 1
(current or most recent)
5.
Name of Employer or
Company
Address of
Employer or Company
6.a. Street
Number and Name
6.b. Apt.
Ste.
Flr.
6.c. City
or Town
6.d. State
6.e. ZIP
Code
6.f.
Province
6.g. Postal
Code
6.h.
Country
7. Your
Occupation
Dates of
Employment
8.a. From
(mm/dd/yyyy)
8.b. To
(mm/dd/yyyy)
______________________________________
Employer 2
9. Name
of Employer or Company
Address of
Employer or Company
10.a.
Street Number and Name
10.b. Apt.
Ste.
Flr.
10.c. City
or Town
10.d. State
10.e. ZIP
Code
10.f.
Province
10.g.
Postal Code
10.h.
Country
11. Your
Occupation
Dates of
Employment
12.a. From
(mm/dd/yyyy)
12.b. To
(mm/dd/yyyy)
Information About Your Parents
Information About Your Mother
Mother's Legal Name
13.a. Family
Name (Last Name)
13.b. Given
Name (First Name)
13.c.
Middle Name
Mother's Name
at Birth (if different than above)
14.a. Family
Name (Last Name)
14.b. Given
Name (First Name)
14.c.
Middle
Name
15. Date
of Birth (mm/dd/yyyy)
16. City
or Town of Birth
17. Country
of Birth
18. Current
City or Town of Residence (if living)
19. Current
Country of Residence (if living)
Information
About Your Father
Father's Legal
Name
20.a.
Family Name (Last Name)
20.b.
Given Name (First Name)
20.c.
Middle
Name
Father's Name
at Birth (if different than above)
21.a.
Family Name (Last Name)
21.b.
Given Name (First Name)
21.c.
Middle
Name
22. Date
of Birth (mm/dd/yyyy)
23. City
or Town of Birth
24. Country
of Birth
25. Current
City or Town of Residence (if living)
26. Current
Country of Residence (if living)
Information
About Your Marital History
27. What
is your current marital status?
Single,
Never Married
Married
Divorced
Widowed
Legally
Separated
Marriage
Annulled
Other
28. How
many times have you been married
(including annulled marriages and
marriages to the same person)?
Information
About Your Current Marriage (including
if you are legally separated)
If you are
currently married, provide the following information about your
current spouse.
Current
Spouse's Legal Name
29.a.
Family Name (Last Name)
29.b.
Given Name (First Name)
29.c.
Middle
Name
30.
A-Number
(if any)
31.
Current
Spouse's Date of Birth (mm/dd/yyyy)
32.
Date
of Marriage to Current Spouse (mm/dd/yyyy)
Current
Spouse's Place of Birth
33.a.
City
or Town
33.b.
State
or Province
33.c.
Country
[Page 7]
Place of
Marriage to Current Spouse
34.a.
City or Town
34.b.
State or Province
34.c.
Country
Information
About Prior Marriages (if
any)
If you have
been married before, whether in the United States or in any other
country, provide the following information about your prior
spouse. If you have had more than one previous marriage, use the
space provided in Part 9.
Additional Information to provide
the information below.
Prior Spouse's
Legal Name (provide family name before marriage)
35.a.
Family Name (Last Name)
35.b.
Given Name (First Name)
35.c.
Middle Name
36.
Prior Spouse's Date of Birth (mm/dd/yyyy)
37.
Date of Marriage to Prior Spouse (mm/dd/yyyy)
Place
of Marriage to Prior Spouse
38.a.
City or Town
38.b.
State or Province
38.c.
Country
39.
Date Marriage with Prior Spouse Legally Ended (mm/dd/yyyy)
Place
Where Marriage with Prior Spouse Legally Ended
40.a.
City or Town
40.b.
State or Province
40.c.
Country
|
Pages 4-5,
Part
5. Applicant’s Statement,
Contact Information, Certification, Acknowledgement of Appointment
at USCIS Application Support Center, Certification, and Signature
|
[Page 4]
Part 5. Applicant’s
Statement, Contact Information, Certification,
Acknowledgement of Appointment at USCIS Application Support
Center, Certification, and Signature
NOTE: Read the information
on penalties in the Penalties section of the Form I-212
Instructions before completing this part.
Applicant's Statement
NOTE: Select the box for
either Item Number 1.a. or 1.b. If applicable,
select the box for Item Number 2.
1.a.
I can read and understand English, and have read and understand
every question and instruction on this application, as well as my
answer to every question. I
have read and understand the Acknowledgement
of Appointment at USCIS Application Support Center.
1.b.
The interpreter named in Part
6.
has read to me every question and instruction on this application,
as well as my answer to each question, in [Fillable Field], a
language in which I am fluent. I understand each and every
question and instruction on this application as translated to me
by my interpreter, and have provided complete, true, and correct
responses in the language indicated above. The
interpreter named in Part
6.
has also read the Acknowledgement
of Required Appointment at USCIS ASC to
me, in the language in which I am fluent, and I understand this
Application Support Center (ASC) Acknowledgement as read to me by
my interpreter.
2. I have requested the
services of and consented to [Fillable Field], who is/is not an
attorney or accredited representative, preparing this application
for me. This person who assisted me in preparing my application
has reviewed the Acknowledgement of Appointment at USCIS
Application Support Center with me, and I understand the ASC
Acknowledgement.
[Page 5]
Applicant’s Contact
Information
3. Applicant’s Daytime
Telephone Number
4 Applicant’s Mobile
Telephone Number (if any)
5. Applicant’s Email
Address (if any)
Acknowledgement
of Appointment at USCIS Application Support Center
I,
[Auto-populate Field with Applicant's Full Name], understand that
the purpose of a USCIS ASC appointment is for me to provide
fingerprints, photograph, and/or signature and to re-affirm that
all of the information in my application is complete, true, and
correct and was provided by me. I understand that I will sign my
name to the following declaration which USCIS will display to me
at the time I provide my fingerprints, photograph, and/or
signature during my USCIS ASC appointment.
I
declare under penalty of perjury that I have reviewed and
understand my application, petition, or request as identified by
the receipt number displayed on the screen above, and all
supporting documents, applications, petitions, or requests filed
with my application, petition, or request that I (or my attorney
or accredited representative) filed with USCIS, and that all of
the information in these materials is complete, true, and correct.
I
also understand that when I sign my name, provide my fingerprints,
and am photographed at the USCIS ASC, I will be re-affirming that
I willingly submit this application; I have reviewed the contents
of this application; all of the information in my application and
all supporting documents submitted with my application were
provide by me and are complete, true, and correct; and if I was
assisted in completing this application, the person assisting me
also reviewed this Acknowledgement
of Appointment at USCIS Application Support Center with
me.
Applicant’s
Certification
Copies of any documents I have
submitted are exact photocopies of unaltered, original documents,
and I understand that USCIS may require that I submit original
documents to USCIS at a later date. Furthermore, I authorize the
release of any information from any and all of my records that
USCIS may need to determine my eligibility for the immigration
benefit that I seek.
I furthermore authorize release of
information contained in this application, in supporting
documents, and in my USCIS records to other entities and persons
where necessary for the administration and enforcement of U.S.
immigration laws.
I
certify, under penalty of perjury, that the information in my
application
and any document submitted with my application
were
provided by me and are complete, true, and correct.
Applicant’s Signature
6.a. Applicant’s
Signature
6.b. Date of Signature
(mm/dd/yyyy)
NOTE TO ALL APPLICANTS: If
you do not completely fill out this application or fail to submit
required documents listed in the instructions, USCIS may deny your
application.
|
[Page 7]
Part
6.
Applicant’s
Statement, Contact Information, Declaration,
Certification,
and Signature
NOTE:
Read the
Penalties
section
of the Form I-212 Instructions before completing this part.
[no
change]
1.a.
I can read and understand English, and
I have
read and understand every question and instruction on this
application
and
my
answer to every question.
1.b.
The interpreter named in Part
7.
read to
me every
question and instruction on this application
and
my
answer to every
question in [Fillable
Field], a
language in which I am fluent,
and I understood
everything.
2.
At
my request, the preparer named in Part
8.,
[Fillable Field], prepared this
application
for
me
based only upon information I provided or authorized.
[no
change]
[deleted]
[Page 8]
Applicant’s
Declaration
and Certification
[no
change]
I
furthermore authorize release of information contained in this
application, in supporting documents, and in my USCIS records,
to other
entities and persons where necessary for the administration and
enforcement of U.S. immigration law.
I
understand that USCIS may require me to appear for an appointment
to take my biometrics (fingerprints, photograph, and/or signature)
and, at that time, if I am required to provide biometrics, I will
be required to sign an oath reaffirming that:
1)
I reviewed and understood all of the information contained in,
and submitted with, my application; and
2)
All of this information was complete, true, and correct at the
time of filing.
I
certify, under penalty of perjury, that all
of the
information in my application and any document submitted with it
were provided or authorized by me, that I reviewed and understand
all of the information contained in, and submitted with, my
application and that all of this information is complete,
true, and correct.
[no
change]
NOTE
TO ALL APPLICANTS:
If you do not completely fill out this application
or fail to submit required documents listed in the Instructions,
USCIS may deny your application.
|
Pages 5-6,
Part 6.
Interpreter’s Contact Information, Certification, and
Signature
|
[Page 5]
Part
6. Interpreter’s
Contact Information, Certification, and Signature
…
[Page 6]
Interpreter’s Contact
Information
4. Interpreter’s
Daytime Telephone Number
[new]
5. Interpreter’s Email
Address (if any)
Interpreter’s
Certification
I certify that:
I am fluent in English and [Fillable
Field], which is the same language provided in Part 5.,
Item Number 1.b.;
I have read to this applicant every
question and instruction on this application, as well as the
answer to every question, in the language provided in Part 5.,
Item Number 1.b.; and
I have read the Acknowledgement
of Appointment at USCIS Application Support Center to the
applicant in the same language provided in Part 5., Item
Number 1.b.
The applicant has informed me that
he or she understands every instruction and question on the
application, as well as the answer to every question, and the
applicant verified the accuracy of every answer; and
The
applicant has also informed me that he or she understands the ASC
Acknowledgement and that by appearing for a USCIS ASC biometric
services appointment and providing his or her fingerprints,
photograph, and/or signature, he or she is re-affirming that the
contents of this application
and all supporting documentation are complete, true, and correct.
Interpreter’s
Signature
6.a. Interpreter’s
Signature
6.b. Date of Signature
(mm/dd/yyyy)
|
[Page 8]
Part
7.
Interpreter’s
Contact Information,
Certification,
and Signature
…
Interpreter’s
Contact Information
4.
Interpreter’s Daytime Telephone Number
5.
Interpreter’s Mobile Telephone Number (if any)
6.
Interpreter’s Email Address (if any)
Interpreter’s
Certification
I
certify, under penalty of perjury, that:
I
am fluent in English and
[Fillable
Field],
which
is the same language specified
in
Part
6.,
Item
Number 1.b.,
and I
have read to this applicant
in
the identified language every
question and instruction on this application
and
his or her answer
to every question.
The applicant
informed
me that he or she understands every instruction,
question, and answer on
the application,
including
the Applicant’s
Declaration and Certification,
and has verified
the accuracy of every answer.
[deleted]
[Page 9]
Interpreter’s
Signature
7.a.
Interpreter’s
Signature
7.b.
Date
of Signature (mm/dd/yyyy)
|
Pages 6-7,
Part 7. Contact
Information, Statement, Certification, and Signature of the Person
Preparing this Application, If Other Than the Applicant
|
[Page 6]
Part 7. Contact
Information, Statement, Certification, and Signature of the Person
Preparing this Application, If Other Than the Applicant
…
Preparer’s Contact
Information
4. Preparer’s Daytime
Telephone Number
5. Preparer’s Fax
Number (if any)
6. Preparer’s Email
Address (if any)
[Page 7]
Preparer’s
Statement
…
NOTE: If you are an attorney
or accredited representative whose representation extends beyond
preparation of this application you must submit a completed Form
G-28, Notice of Entry of Appearance as Attorney or Accredited
Representative, or G-28I, Notice of Entry of Appearance as
Attorney In Matters Outside the Geographical Confines of the
United States, with this application.
Preparer’s Certification
By
my signature, I certify, swear, or affirm, under penalty of
perjury, that I prepared this application
on behalf of, at the request of, and with the express consent of
the applicant. I completed this application
based only on responses the applicant provided to me. After
completing the application, I reviewed it and all of the
applicant’s responses with the applicant, who agreed with
every answer on the application. If the applicant supplied
additional information concerning a question on the application, I
recorded it on the application. I have also read the
Acknowledgement
of Appointment at USCIS Application Support Center
to the applicant and the applicant has informed me that he or she
understands the ASC Acknowledgement.
Preparer’s
Signature
8.a. Preparer’s
Signature
8.b. Date of Signature
(mm/dd/yyyy)
|
[Page 9]
Part
8.
Contact
Information, Declaration,
and
Signature of the Person Preparing this Application, if
Other
Than the Applicant
…
Preparer’s
Contact Information
4.
Preparer’s Daytime Telephone Number
5.
Preparer’s Mobile
Telephone Number (if
any)
6.
Preparer’s Email Address (if any)
Preparer’s
Statement
…
NOTE:
If you are an attorney or accredited representative, you
may be obliged to submit
a completed Form G-28, Notice of Entry of Appearance as Attorney
or Accredited Representative, or Form G-28I, Notice of Entry of
Appearance as Attorney In Matters Outside the Geographical
Confines of the United States, with this application.
Preparer’s
Certification
By
my signature, I certify,
under penalty
of perjury, that I prepared this application
at
the request of the applicant.
The applicant
then
reviewed this completed application
and
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant’s
Declaration and Certification,
and that all of this information is complete, true, and correct.
I completed this application
based
only on information that the applicant
provided
to me or authorized me to obtain or use.
[no
change]
|